Provider Demographics
NPI:1184132417
Name:PEACOCK, FALLON
Entity type:Individual
Prefix:
First Name:FALLON
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 DOGWOOD PLACE DR
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-2839
Mailing Address - Country:US
Mailing Address - Phone:501-722-2044
Mailing Address - Fax:
Practice Address - Street 1:200 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-3424
Practice Address - Country:US
Practice Address - Phone:501-847-5660
Practice Address - Fax:501-847-5662
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health